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General NPI Number Information
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NPI Number | 1245558519
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Entity Type | Organization
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Legal Business Name | EYECARE WELLNESS CLINIC P.L.L.C.
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Dates
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Enumeration Date | 05/12/2010
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Last Update Date | 05/12/2010
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Provider Practice Location Address
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Address Line | 4848 S 900 W
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City | RIVERDALE
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State | UT
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Zip | 84405-3726
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Country | US
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Telephone | 801-627-9868
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Fax | 801-627-9870
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Provider Business Mailing Address
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Address Line | 174 OAKRIDGE DR
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City | FARMINGTON
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State | UT
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Zip | 84025-3625
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Country | US
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Telephone | 801-627-9868
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Fax | 801-627-9870
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DAVID BOYLE BURNETT
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Credential | O.D.
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Telephone | 801-309-4832
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 5676092-9934
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License Number State | UT
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